PROCEDURAL STEPS: Maintain the patients ABCs Determine that the patient requires endotracheal intubation Assemble required

equipment Position the patients head three axes, those of the mouth, the pharynx, and the trachea must be aligned to achieve direct visualization of the vocal cords Sniffing Position the head is extended and the neck is flexed A folded towel may be placed under the patients shoulders and neck to assist with positioning Suction the patient (no longer than 30 seconds) Oxygenate patient for 1 minute with 100% Oxygen Insert the laryngoscope blade and place endotracheal tube Laryngoscope handle is held with the left hand Insert the laryngoscope blade in the patients right side of the mouth and sweep to the center of the mouth When a curved blade is used, the tip of the blade is advanced into the vallecula (i.e. the space between the base of the tongue and the pharyngeal surface of the of epiglottis) When a straight blade is used, the tip of the blade is inserted under the epiglottis Lift the laryngoscope blade in an upward motion The handle must not be used with a prying motion, and the upper teeth must not be used as a fulcrum Visualize the vocal cords Using the right hand, insert the endotracheal tube until you see the cuff pass through the vocal cords. Advance the tube an additional to 1 inch for proper placement. Remove the laryngoscope carefully from the patients mouth Remove the stylet from the endotracheal tube

** NOTE: The insertion of the endotracheal tube should be no longer than 30 seconds from the time you stop ventilating the patient until the time you remove the stylet. If you are unable to place the endotracheal tube within 30 seconds, withdraw the endotracheal tube and laryngoscope, ventilate the patient (Step f.) and start again Ventilate the patient with two breaths Check for proper placement with these first two ventilations by: Observing the chest rise and fall with each ventilation: Proper placement will cause both lungs to inflate with each ventilation Auscultating for bilateral breath sounds: Breath sounds will be completely absent if placed within the esophagus. Remove the endotracheal tube and attempt placement after 1 minute of oxygenation and ventilation. If the tube is placed too far down the tracheal tree, a right mainstem intubation can occur. This prevents air from going into the left lung. To correct this problem, continue to ventilate patient and slowly withdraw endotracheal tube - inch or until bilateral breath sounds are heard. Auscultating over epigastrium for gastric sounds: Placement of the endotracheal tube into the stomach / esophagus will produce gurgling sounds in the epigastric area. Remove the endotracheal tube and attempt placement after 1 minute of oxygenation and ventilation. Inflate the endotracheal tubes cuff with 10 ccs of air: Inflation of the balloon serves two purposes: Holds tube in place Acts as a barrier and prevents fluids from entering the lungs Ventilate the patient with two breaths Insert oropharyngeal airway Ventilate the patient with two breaths Tape endotracheal tube securely in place Continue to ventilate patient (1 breath every 5 seconds) and suction as necessary

8. PROCEDURAL STEPS FOR THE REMOVAL OF THE ENDOTRACHEAL TUBE (EXTUBATION) Determine that endotracheal intubation is no longer required Patient begins spontaneous respirations Medical Officer orders removal of endotracheal tube Remove tape from endotracheal tube Remove oropharyngeal airway from patients mouth Suction the endotracheal tube, the patients mouth, and the patients posterior pharyngeal area Deflate the endotracheal tubes cuff Withdraw the endotracheal tube with one smooth motion Monitor the patient for signs / symptoms of respiratory distress or difficulty